There are several ways to go about answering this question, but the key is to have a plan. Here is the strategy I used to attack this problem head on. Note, this assumes that you are applying across the country and have roughly 10 to 20 interviews. If you are applying in one region, or are in a situation that requires more interviews, this strategy may not be for you.

No one really discusses the logistics of what happens after you submit ERAS. Sure, everyone understands that programs review your ERAS application, look at your grades, letters, and personal statement, and then decide to send out interview invites. You accept, go interview, then both sides rank, and you wait for Match Day. This model works great for one program, but what happens when you are dealing with 10 to 20 programs simultaneously? And, the programs send out invites at different times on a rolling basis?

To solve this problem, there are a few key principles: submit early, block out time, stay up-to-date, be inquisitive, and be a deal hunter.

Submit Early - There are two seasons to be aware of: the invitation season and the interview season. The invitation season runs from whenever you submit to roughly early December. The interview seasons lags this by about a month and a half, so most interviews run from late October to late January. However, to maximize your timeframe to receive interviews and schedule them, you have to submit your ERAS as soon as possible. Of course, you want to do a good job and have a complete application, but you need to be proactive in getting your application in so you can start receiving invites!

Block Out Time - If you are applying all over the country, it is a good rule of thumb that the further west you go, the later the invitations. That means, you should try to block out months based on regions: November for East Coast, December for Midwest/South, and January for West Coast programs. If you do this, you can save a lot of money by scheduling one flight for multiple interviews in the same region. It also helps you respond when programs offer multiple dates across all three months. Keep in mind that most programs do not interview the week of Thanksgiving as well as the weeks around Christmas and New Year. Remember, interview spots fill up fast so you want to respond to an invitation as soon as possible!

Stay Up-To-Date - Use the message boards either specific for your specialty or on Student Doctor Network to know when programs send out invitations. While this can be nerve-wracking sometimes, it helps you know when you have not heard from a program whether the program has already sent out invites to others, or whether to remain patient. At the same time, you want to keep your resume and information up-to-date as well.

Be Inquisitive - If you have not heard from a program, or know they have already sent out a round of interviews, it can sometimes pay to email the program coordinator to reiterate your interest. A lot of times, programs are trying to decide between many very similar looking applicants, so this extra show of interest can help push your application to the top and win you that invite.

Hunt For Deals - Traveling and interviewing is expensive. Between the flights and hotels, many interviewees end up spending thousands of dollars. Since there's no real way around this, it's important to be on the lookout for deals. Try to stay with friends, fly with the same airline to rack up frequent flyer miles and potentially a free flight, stay close to your hospital, and use public transportation to minimize taxi cab / rental car costs. Those saved dollars will really add up over the interview season.

Tuesday, November 10, 2009

Ah, the winter season. A time for Christmas, Hanukkah, Kwanzaa, Diwali, and other holidays I am forgetting. A season of giving. But, alas, what to give?

In the past, I've written about practical gifts and must have gifts for medical students and health professionals. This time though, it's just going to be a wish list, plain and simple. Most of it is medically-related, sometimes a stretch, but honestly, some of it just good stuff one might want to have. C'mon, you (or your recipient) is in medical school! A doctor doesn't have to treat only patients all the time - sometimes a doctor should treat themselves too! Now, granted, these are wishes for particular gifts. Maybe you are wishing you were AOA or you could travel the world or perhaps lose weight quickly (quite a challenge in medical school with busy rotations and studying!) Not every wish can be encapsulated by a gift item though. Regardless, hopefully some of these gifts will lift your spirits nonetheless!

First up, the Kindle. What's not to love about this device? It's almost as thin as a magazine, can download books wirelessly just about anywhere, holds up to 1500 books, has a super-sharp crisp screen to read, and can even read out loud to you! As a medical student, you can have all your medical reference textbooks in their full-size glory in one easy to carry device. In fact, some medical schools are starting to implement support for Kindle for all their resources (see this blog post about Kindle at Harvard Medical School). Yes, it's a little pricey, but that's a one-time cost - the total cost ends up being cheaper as books cost less on the Kindle. Besides, using a Kindle is environmentally friendly. Heh, and it just looks plain cool. And that's why the Kindle is tops on the wishlist this year.

Those commercials got to me - using a Flip Video Camera to record the goofy moments in life seems fun. From a med student point of view, it's also useful for recording bits of a lecture or perhaps for composing a skit for your school's version of fall follies or senior skits. Not sure what I'm talking about? Clearly you haven't seen Jizz In My Scrubs.

This thing is frickin' awesome. First, the 5 in 1 combo tool just looks way more professional than the standard issue orange reflex hammer. Frankly, I lost mine a while back and have felt none the lesser for it. Second, you can really examine people thoroughly with this device. Instead of making ad hoc solutions to assess pin-prick sensation, you can use an appropriate tool for it. I guess I'm a sucker for gadgets, but the 5 in 1 - Neurology Combo Tool actually seems useful.

What can I say? The Apple iPod Touch is simply amazing. It plays music, it surfs the webs, it does apps. In some ways, it's even better than an iPhone - no lousy contract, but still get all the perks. From a med student standpoint, it's great because many apps have been developed for the OS that are relevant for medical professionals, and many are free. For example, you can get Epocrates on your iPod Touch now. Many hospitals provide Wifi service, so you can also use your iPod Touch to do research in between rounds. The device basically does it all.

Sunday, November 01, 2009

One of the most difficult parts of the first year medical school is distilling a large volume of information into easily digestible parts. Here are some links to online resources you might find helpful.

Tuesday, October 27, 2009

For medical education, the question is not only what to teach and what to leave out but also how to teach it. Alfred North Whitehead in his famous essay 'Science in the Modern World' described a situation in which the explosion of knowledge in modernity made the 'Renaissance Man' no longer possible, and that to be effective, a modern person had to content themselves with being a specialist, and this was in the 1920's! I think this predicament of modernity creates a real tension for medical education, especially, because the human body is a microcosm of the universe, of the whole of science, not only in the sense of complexity but in the sense that a person's health is bound to it, so it is very difficult for any person studying medicine to leave off something potentially important just because the mind has limited capabilities. Furthermore, there is a tradition which makes it hard for any teaching generation to make things easier for today's students than they had it themselves in their own education. However, the rate of increase of the knowledge base means that even if the discipline doesn't change, the disposition towards the knowledge among educators has to change. Medical students can't learn everything. In biochemistry alone, medical students are asked to retain an incredible amount of information regarding mechanism after mechanism, but this was true even fifty years ago. However, in the intervening years, students have been given a new encyclopedia to learn in the field of molecular biology. With gene expression alone, there are now elaborate signaling pathways and mechanisms like alternative splicing and RNA interference which have been elucidated only in the past ten years. So there needs to be a lot of debate about what to teach and what not to teach.

Of course one important standard is whether a piece of information is relevant to clinical judgment. Something as fundamental as the Krebs cycle is likely only important in clinical practice for a subset of metabolic disorders. Within every clinical specialty there are fundamental principles from basic science which are important for understanding of symptoms and treatment on a daily basis, but not for other specialists. Bernoulli's Principle and Poisseuille's Law for the cardiologist. Solution and acid-base equilibria for the nephrologist. Hooke's Law for the orthopedist. An infectious disease specialist is not going to think about these things very often I suppose. In fact, the specialists themselves probably don't think about them too much on a daily basis, except in difficult cases, but the knowledge must be there in the first place for the specialist's education to have been coherent when they received it. This is where I have an issue with the complaints of many medical students that much of the science they learn is irrelevant information. Students complain about learning every structure in the Krebs cycle, but this is the wheel at the center of the living system. To understand energy flow in metabolism makes a great deal else coherent, although I have big problems with how the Krebs cycle and a lot of biochemistry is taught. In my opinion, if instructors felt they could use the field of reference of physics and general chemistry in a sophisticated way to animate the presentation of the Krebs cycle, it would mean a lot more to students.

If you read discussions among medical educators, you see a lot of advocacy for more emphasis on clinical experience and communication at the expense of basic science. Medical educators may be giving up on making medical school an experiment in finding the maximum possible amount of information a human mind can hold, which is probably a good thing. It may be that there is cost benefit to teaching doctors to be better communicators because it leads to better outcomes for patients without too much trouble. Convincing people to quit smoking has done more against cancer than understanding the mechanism of histone acetyl transferase, at least so far.

The proposition that animates my own work is that a more effective curriculum at the earlier stage would prepare entering students significantly better for the challenges of understanding and retention they face in medical school, by which I mean the education they receive at the fundamental level of physics, chemistry, organic chemistry and biology. Medical school would be more vivid if students learned the fundamental physical and biological sciences within a combined curriculum that builds on itself, not within disconnected modular courses. How can a person understand free energy change in chemistry without mechanics, electrodynamics, and thermodynamics from physics? How can you understand oxidative metabolism without oxidation reduction? Being a person who has worked very closely with many small groups of premedical students, taking them through the basic sciences in review more times than I want to admit, I'm burdened with knowing how little conceptual fluency entering medical students actually possess after their undergraduate years that would help them unify the enormous encyclopedia already in their heads, let alone what is coming in medical school.

So I made the WikiPremed MCAT Course because I hoped it would benefit people. It’s just a small part of the whole movement to make education more accessible online. I also hoped it would be a way to share some ideas about designing the basic science curriculum to be more appropriate for future doctors at the undergraduate level. The sequence of topics and goals in the course represents my best effort at what a unified, interdisciplinary, spiraling curriculum for basic science would look like (without lab component). I think medical school would be more interesting and enjoyable if students were prepared by a science program that followed a sequence like this one, where chemistry comes out of physics and the biological sciences out of the physical sciences. If anyone is interested, they can go visit, at least to see what a person is capable of who gets so deep into a project they can only double down. I'm probably too close to the work to see it's problems clearly, so I am very interested in substantive criticism, although any encouragement is also welcome.

Saturday, October 24, 2009

Anatomy is a fundamental part of any medical student's education, and usually it starts early on in the first year. The education is usually a mix of didactic lectures as well as time spent in an anatomy lab, dissecting cadavers. Some have suggested switching to a method of instruction utilizing technology for prosections, avoiding the need for cadavers, but most medical schools still have a formal anatomy lab. Perhaps one day, most anatomy courses will be taught online at programs like Indiana Wesleyan College with a hybrid classroom component that only involves the anatomy lab, but until then... you gotta study!

Repetition - Whatever you learn, repeat. A lot. On different cadavers, different angles, different lighting even. You need to have a fundamental understanding of the visuospatial relationships between structures as well as the range of normal variation in them. Otherwise, on exams, you will simply see a mass of flesh and get confused.

Know the ideal - Use Netter's Atlas of Human Anatomy to learn the ideal relationships beforehand. Otherwise, you can repeat all you want, but each time you'll just see 'mass of flesh.'

Learn tissue features - Know the characteristics that differentiate nerves, arteries, veins, and muscles, both by look and feel. Sometimes, these structures run together as in the brachial plexus, and can be difficult to differentiate.

Study in a group - Having someone quiz you and prod the lacunae in your knowledge can help you realize your weak spots and strengthen them. Perhaps gastric anatomy always confuses you; maybe its neuroanatomy structures. Either way, a study buddy can help you see things in a new light and learn the material in a way that sticks.

Study prosections - if your anatomy lab has idealized dissections, also known as prosections, study those well. It wouldn't be too surprising to see some of these show up on your anatomy practical exam.

Study hard, and anatomy will become the foundation for the rest of your medical learning.

Sunday, September 27, 2009

In my continuing series on posts for first year medical students, I decided to write a post on study tips and strategies for first year students. Of course, some of these tips could apply to any student, but there is a definite adjustment that has to be made for studying medical knowledge. Some of these things I learned from friends; some, from my own mistakes. Hopefully you can incorporate them into your own study strategies to be a successful medical student.

Study every single day - Being a good student requires developing good study habits. As cliche as this is, it is really really important in medical school, much more so than in college or high school. There is a huge volume of material being presented, and it is very easy to fall very far behind. Even if you can't study every single day, try to read at least a little bit whenever you can.

Translate the notes you receive into your own condensed, easy-to-read version - This helps you internalize the knowledge in a way you can easily access. If you find yourself having trouble doing this, it is usually a good sign that either the material was not presented well or you are not fully understanding it (or both). Besides, such study guides will help immensely down the road when you have to study for USMLE Step I.

Use visual cues - Imagine 10 years from now (or even 2 years), you are participating in a gastric bypass bariatric surgery procedure. The procedure is being doing laparoscopically, and the attending physician points to a section of the GI tract, asking you to identify it. If you study visually, this will trigger images from your basic science years, and such identification should be easy. However, if you only study via text or via one view of the abdomen, such identification may prove very challenging.

Take study breaks - I know, this contradicts the tips that came before. But it is really important to maintain balance in studying, and to take appropriate study breaks. I would suggest taking a 2 to 5 minute break every hour, and a 30 minute break every 3 hours. And, in general, have one day a week where you study only an hour or not at all. Your mind needs time off to process all the information you are trying to cram into it.

Study in a group - Again, somewhat cliched advice, but I think the key here is to choose your friends wisely and to strictly limit how much time you study with them. Ideally, you should do all your studying on your own, and use group studying time as a review or to clarify confusing points. The sessions should be rapid fire and limited to no more than an hour or two a week. I studied with friends much more than this amount, but looking back on it, I am not sure how efficient such studying was. The ideal study group is one with similar views on studying and work ethic that complements your knowledge base well.

Study what matters - A lot of minutiae will be presented to you during these early years, and the ideal student will learn it all. However, pragmatically, this is not possible for most of us. What is important to remember is that most of your examiners are clinicians first, so focus on what the clinically relevant questions will be. In fact, looking at USMLE Step 1 books and review guides can be very helpful, as these are the types of clinical vignettes people use to test basic science material. For example, in infectious diseases, knowing the structure of the bacterium is ultimately not as important as knowing how the disease presents and how you treat it. When push comes to shove, focus on clinical presentation, diagnosis, and treatment over the more 'basic science' aspects of the material.

When in doubt, ask - Simple advice, but sometimes, we are all averse to asking questions for fear of looking dumb or inconveniencing the professor. However, in this age of email, it never hurts to shoot off an email with well-phrased questions than you have already tried to answer. Whenever I did this, I usually received a thoughtful response. In retrospect, I wish I had done this more. This not only helps academically, but it helps to also develop relationships with people in fields you may be interested in in the future when you have to choose a specialty.

Enjoy what you are doing - If you find yourself getting bored while you study, stop. Take a break, and think of a way to make what you are studying interesting, whether that is by turning it into a game, making it interactive, more visual, or even reading interesting case reports online of a related disease. Sometimes, pegging the knowledge onto a case report or vignette can make the information much more "sticky" in your mind, which is all that matters. The New England Journal of Medicine has many such case reports, most excellently written, as do many other journals.

Best of luck in your first year! Developing good study habits now will not only serve you during the rest of medical school, but throughout your medical careers.

That being said, there is a broad discussion online about what constitutes a good stethoscope. For example, Half MD argues against the Littmann Cardiology III in favor of the Welch Allyn Tycos stethoscope:

I don’t like it. I haven’t been able to hear as well with it as the marketing propaganda would claim. The fans will instantly cry out, “But it has a tunable diaphragm.” To which I would respond, “Do you even know what a tunable diaphragm is? And furthermore, if you pay any attention to the research that was conducted on stethoscopes beginning over 50 years ago, you’d realize that a tunable diaphragm is the exact feature that a stethoscope should not have.”

I prefer the Welch Allyn Tycos DLX. The sound quality is much, much better compared to the Littman. It has interchangeable ear pieces that come in various varieties of stiffness so that the user can choose based on comfort level. Finally, the diaphragm can be easily changed to a pediatric version. All I have to do is unscrew the adult version and then replace it with a pediatric one to convert my stethoscope into a listening device for the kids.

Buying an expensive stethoscope because you don’t want to lose out is an absolutely ridiculous reason. Unless you’re buying a China-made $17 stethoscope, there’s almost no loss in skills of cardiovascular/respiratory/etc. examination with a $95 Littmann Classic II SE compared to the rest. Don’t let your friends pressure you into this.
That said, J. supports the 3M Littmann Classic SE, and not because it has tradition on its side. It is light, bendy (knots can be tied in it), of good quality, available in grey and most importantly, way cheaper than its more illustrious counterparts.
And of course, J. refuses to cave in to herd mentality: "everyone’s using at least a Cardiology III, mustn’t lose out!"

Ultimately, my view is that any of the Littmann or Welch-Allyn stethoscopes will provide decent enough sound quality and functionality to get through medical school. The two sets of students I would caution to think a little more deeply about their decision is anyone interested in cardiology or in pediatrics. For the cardiology people, investigate your decision a little more closely and try out several scopes to see which works best for you. Read reviews online and ask cardiology fellows and attendings for their advice. For the peds people, consider getting a pediatric sized stethoscope. I am not sure if it actually helps you hear heart sounds that much better than a regular adult stethoscope, but it makes sense given the patient population.

Confused yet? As I said before, the default gold standard seems to be the Littmann Cardiology III stethoscope so try that first. If you already have a stethoscope, what type do you have? Are you happy with how well it helps you during your cardiovascular and pulmonary exams?

Sunday, September 13, 2009

While I am sure your classes will provide you with curricula and suggested texts to read, there are several textbooks that any first year medical student should consider buying as part of their long-term collection of books. Looking back at some of my book purchases, it is shocking to see the books that I omitted and the ones I blew hundreds of dollars on only to have them collect dust.

What Books Should Every First Year Medical Student Own?

There is no definitive list of books, of course. But, I think the list below would serve any medical student well, since these topics are cornerstones of any medical education. Besides, we all have to take USMLE Step 1 at some point, right?

Every medical student will have to master anatomy regardless of what field they go into. I really liked how well-drawn and clear the Netter drawings and illustrations were. Even now, a few years later, any time I have a question about anatomy, it is the first text I turn to. Although I never used them for studying, I am aware that some find the Netter's Anatomy Flash Cards to be quite helpful as well.

I also found Color Atlas of Anatomy: A Photographic Study of the Human Body to be helpful. Seeing the anatomy in photograph form is much more similar to how you would see it on an anatomy practical, or actual patient. It helps to open up both Netter's and the photographic atlas to correlate the ideal anatomy to the actual stuff.

As I have mentioned before, Step 1 is a high-stakes test for any medical student. Obtaining First Aid early and reviewing it as you learn the material initially will just solidify the content for you two years down the road when you have that giant test to study for. In fact, if you annotate the book as you go along, you will create this wonderful resource for yourself that you are intimately familiar with when it comes time to crack open the books to study for the boards.

All the major techniques for history taking and physical exams are covered in this book. I like how the diagrams are clear and the sidebar notes highlight important points and diagnoses. The book is really indispensable when you are first learning basic exam technique and the significance of certain results. If you are interested, check out the pocket version as well: Bates' Pocket Guide to Physical Examination and History Taking, North American Edition

Infectious diseases is another cornerstone of any medical education. This book uses numerous techniques to help you learn about infectious agents, including many (bad) puns, funny diagrams, explanatory text, and tables grouping similar agents. It really is easy and even fun to read, which makes learning this otherwise seemingly disparate set of information not so bad. And yea, it's easy to review when Step 1 rolls around too.

The definitive book on general pathology. I thought the book did an excellent job not only describing the underlying pathology of almost any major disease you can imagine, but it often clearly explained the physiology as well. Definitely the best reference book I bought and the one I used most often, especially when very detailed questions came up during pathology and immunology.

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I still own all these books, used them throughout Step 1 (and Step 2) studying, and still refer to them as needed today. Do you know any other books that you think every pre-clinical medical student should have? Any books you disagree with in the list above? Leave a comment with your best book suggestions.

Sunday, September 06, 2009

Welcome Class of 2013! By now most of you are a few weeks into the medical school experience. Hopefully you have had time to settle into your new surroundings, make some new friends, and perhaps learn a thing or two.

You may have also noticed that medical school requires a different approach to studying. The way I look at it, to get into medical school, you had to be broadly talented, doing well in many subjects and perhaps especially well in one or two. The emphasis was more on being able to apply knowledge and problem solve (remember all those orgo and physics problem sets? Yea... ) However, the emphasis shifts drastically in medical school: it is simply an issue of rote memorization now. A person with photographic memory but no prior science background would likely be at the top of any medical school class, at least during the pre-clinical years. Another way to look at it is the information you are now expected to know is an oceanwide but only an inch deep.

How does one manage to internalize all this information in the short span of two years? I think the main thing (which I wish I had picked up on earlier) is learning from a clinical perspective and utilizing the advice of those that have gone before you heavily. Unlike prior educational experiences, there is much to be gained in medical school from talking to upperclassmen about specific courses and what is truly important down the road. For example, our infectious disease class spent a lot of time categorizing different viruses into single stranded or double stranded, positive or negative, and other features. However, these barely showed up on the test. And, from a clinical perspective this makes sense: the molecular features of the agents is only relevant to the virologists; the clinician could care less.

Thinking clinically is one of the keys to doing well in the pre-clinical years, especially if your test is being written by a clinician. The next few posts will serve to help first year medical students with various first year queries, such as which books are most helpful to first years, regardless of your med school or coursework. Good luck!

Tuesday, September 01, 2009

Along with the surgery rotation, the internal medicine rotation is arguably the most important rotation you will take during your clinical training in medical school. Of course, if you choose to specialize or go into another primary care field like pediatrics, those rotations will count a great deal. However, every student will be greatly benefited by doing well in medicine and surgery. The grade you receive on this rotation is on par with your surgery grade and second only to the USMLE Step 1 score in terms of factors that residency program directors evaluate. Your grade will likely be a mix of clinical evaluation and your shelf exam score. However, since the evaluations tend to average out to the same values, the shelf exam is what separates the great students from the good ones.

To do well on the rotation requires the usual medical student qualities of diligence and compassion, but the three main things to know are: know your patient, know your physiology, and know your pharmacology. If you know those three things and study hard, you will succeed. But, how does a medical student acquire all that knowledge in short period of time? The key is studying good resources efficiently. Here are my recommendations:

This review book covers major areas within medicine by organ system. It is well-organized and easy to read, with many tips and mnemonics detailed in the margins. I also found the flow charts helpful for thinking through certain conditions, such as what to do for a hypoxic patient.

If you are familiar with the Case Files series, then you know that these books are a good way to get up to speed on any clerkship. They are quick to read, but really help you understand the basic concepts and cases within a specialty. Read this book right before your rotation starts or during the first week. The book contains 60 cases of common diagnoses within internal medicine, specifically a patient vignette, followed by a description of the workup, background on the diagnosis, and review questions.

While on the wards themselves, you cannot refer to a full reference book for information. That's where Pocket Medicine comes in. The guide is a fairly comprehensive reference that fits in the pocket of your white coat. While it does not go into detail about pathophysiology of disease, it has a lot of information about clinical guidelines, relevant trials, and most importantly, how to manage common medical problems, from congestive heart failure to hyperkalemia to lower GI bleeding.

If you can master the content in these three books, you will do well on your internal medicine rotation. And, as always, remember to keep your differential broad and your therapeutic options broader.

Saturday, August 15, 2009

Hyponatremia is not an uncommon finding among patients, especially hospitalized ones. There are many etiologies of hyponatremia, so it is important to understand the concepts behind sodium and water balance. Unlike some other lab abnormalities which may have various causes but one treatment, the treatment for hyponatremia can differ quite a bit depending on the cause so it is very important to determine the root cause of a low sodium level.

What is hyponatremia?

Hyponatremia is defined as a sodium level less than 135 mg/dl. Although it is a sodium level, it is generally interpreted to mean that there is an excess of free water in the serum relative to the usual level of sodium. This is a key concept as we go forward in the work-up.

Hyponatremia And Serum Osmolarity

The first question to ask yourself is: Is this a true hyponatremia? In other words, is there truly an imbalance between the ratio of sodium to free water. Sometimes, such as in diabetic ketoacidosis, there is an influx of another osmolar substance into the blood, namely glucose. The extra osmoles cause a shift of water into the intravascular space, thus artificially depressing the serum sodium concentration. In these situations, the serum osmolarity is high, and the hyponatremia will resolve automatically once the other osmoles are cleared. To calculate what the true sodium level would be in the face of hyperglycemia, take the current level, and add 1.6 times the glucose level minus 100 divided by a hundred. So, if the sodium level is read as 120, but the glucose level 1100, then the true sodium level is 120 + 1.6 * (1100 - 100)/100 = 120 + 16 = 136, or a normal sodium level.

Hyponatremia And Volume Status

If the serum osmolarity is normal, then this is likely a true hyponatremia, so next consider volume status. If the patient is dehydrated, then the low sodium is likely due to the compensatory response of ADH, and the treatment is to gently rehydrate the patient using normal saline. However, if the patient is volume overloaded and edematous, think about causes such as cirrhosis, renal failure, or congestive heart failure and treat those as needed. If the patient has normal volume status, they might have syndrome of inappropriate antidiuretic hormone (SIADH) or something more esoteric like psychogenic polydipsia or beer potomania. In this situation, the treatment is to free water restrict the patient. If the diagnosis is SIADH, you should also try to investigate the cause of the SIADH and treat that as well.

There may be more rare causes of hyponatremia that require more specific work-up, but the general treatment for most causes is described above. When rehydrating with normal saline, remember to rehydrate slowly with no more than 0.5 mg/dl increase in sodium per hour. If you go faster, you risk causing central pontine myelinosis and locked-in syndrome. However, if the patient is having neurologic symptoms due to the hyponatremia, then it is okay to use 3% saline because the goal at that point is simply to get the sodium level up and stop the neurologic problems. At the end of the day, always keep in mind that the sodium level truly represents the body's free water status.

Saturday, August 01, 2009

Let's say you are trekking in the Himalayas and suddenly become short of breath. Even though you are on your way to Annapurna Base Camp in a remote corner of the world, you would most likely be taken to a local clinic and have a plain film chest x-ray taken of your chest to help determine the etiology of your dyspnea, just like in any other part of the world. This post is not a comprehensive account of how to read a chest x-ray, but rather a collection of tips and tricks that should help one read most plain chest x-ray films [...]

Tuesday, July 28, 2009

My first month of internship is coming to an end. I did a month of medicine wards. The hours are long, but it's been interesting. Here are a few quick tidbits from my month:

One patient was a little too happy that I attempted to say hello to her in her own language. As I began to examine her with my gloved hands and stethoscope, I said "Hello" in her language. She suddenly lit up, grabbed both my hands with her own, said "Hello!!!" and proceeded to kiss my gloved hands. Sadly, I think this was actually more sanitary than had she kissed my bare hands.

Constipated patients get used to people asking them about their bowel movements. However, a select few get a little too worked up about their situation. One patient was so happy that he finally had a BM, he very generously saved it for me to examine when I returned the next day. Thanks, buddy.

Nurse: Doctor! The patient is in extreme pain! 10/10! I think we should really give him something for his painDoctor: I just went to see the patient, who I am covering for another doctor. He is sleeping soundly and snoring.Nurse: Yes, but when he wakes up, he will be in extreme pain!Doctor: ...

One time, a fellow intern admitted a patient, who soon after admission had a code blue. In this case, the code blue was because the patient had stopped breathing. This could happen to any patient, but it was funny to hear the intern remark "But he was satting 100% on room air when I left..."

Patient's reason for admission: I ate a bad plum and then vomitted, but I feel better nowThe hospital's reason for admission: rule out heart attack... what?

In general, a quick assessment of mental status is to ask the patient their name, their location, and the date. If they know all three, they are "alert and oriented times 3". However, it's sad when I examine a patient and realize they are more alert and oriented than I am, especially about what day it is.

Me: I spoke with Jennifer, the nurseUnit clerk: Which Jennifer?Me: Uhhh... the one I just spoke with?Clerk: We have 4 nurses named Jennifer on this floor: Jennifer C, Jennifer T, Jennifer P and Jennifer J

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Saturday, July 18, 2009

Wards often cause much consternation for medical students, interns, and residents. This post will be half humorous, half serious, but hopefully all helpful. These are going to be practical tips about your workflow. If you're worried more about looking good on rounds, might I suggest First Aid for the Wards. You might also want to check out:

Buy one of those clipboard/organizer deals. Unless your hospital has a full EMR, you will be filling out forms. A clipboard with storage lets you carry around forms so you don't have to hunt for them on each unit where they will be inevitably hidden a different, illogical location.

Find out where the good/clean restrooms are. I remember hearing this on the interview trail and thinking it a joke, but it is so so true.

Same goes for figuring out where to get food quickly and cheaply.

Sometimes people get all worked up on keeping notecards with every single lab value their patient has had. This is a giant waste of time. All you need are the latest labs, and perhaps the previous values for labs that come back abnormal. If someone asks you a sodium level from a week ago, they are being unreasonable and should look it up themselves.

Figure out how to round in a path that makes sense. Start with the sickest patient, but then walk around in a logical way.

Do as complete an exam as you can during your initial H&P, and then do as little as possible while still addressing the patient's major issues during each follow up. There's no point in not checking pulses initially, but then doing fully neuro exams everyday, unless you're specifically asked to do so.

Use the time when you page or return a page and are put on hold to do other mindless things, like collect labs.

Don't stress too much. Things could be worse - at least you're not the one who is sick in the hospital, right?

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Saturday, June 27, 2009

Regular readers of this blog have probably surmised from my posts (or lack thereof) that I am starting residency now. Part of the prerequisites to starting internship is Advanced Cardiovascular Life Support (ACLS) certification. Therefore, I recently took an ACLS course and became certified.

The ACLS course I took was structured to be taught over 2 days, from 8 AM to 5 PM. At the end of the course, there was a practical and written exam. If we passed those, we received our certification, stating that we were ACLS certified for two years.

The course cost was approximately $200 (covered by my program). Additionally, one must purchase the ACLS provider manual for approximately $40 (maybe I'll be reimbursed someday?). In reality, the course ran from 8 am to about 4pm the first day, and 8am to about 1pm the second day. It could have been even shorter, but I think they were required to keep us there for a certain amount of time.

Preparing For The Advanced Cardiac Life Support Training

While preparing for the course is not 100% essential, it is very very helpful. I messed up here, because the email I received only mentioned the preparation in an attachment, not the body, of the email. Furthermore, when I called to confirm my course registration, all the person said on the other end was that I had to show up and wear comfortable clothes. Regardless, what I should have done is purchase the Advanced Cardiovascular Life Support Provider Manual published by the American Heart Association, read all the cases beforehand, and taken the pre-tests. The AHA ACLS Manual is the only official training manual for these courses, so it pays to get it early. Also, on the first day, when you register, they ask you for your pre-test scores. If you do not have passing pre-test scores, they explicitly state that they cannot guarantee that you will receive certification by the end of the two day course.

Advanced Cardiac Life Support Training Day 1

As I stated above, I arrived the first day in comfortable clothes... but without a Advanced Cardiovascular Life Support Provider Manual. I scrambled to buy one and began to read through the cases as introductions were made. Needless to say, I didn't get much out of the first hour. After introductions, the large group of us taking the course (about 30) were split into groups of 5 or 6. These small groups are where we received the bulk of our training.

The rest of the first morning was spent going over cardiopulmonary resuscitation (CPR) basics. Nowadays, this is also referred to as basic life support, or BLS. The last time I trained for BLS was in 8th grade, but I remembered a reasonable amount. Still, the ACLS course explicitly states that ACLS certification is not the same as being BLS certified. To me, that makes no sense as one cannot pass the ACLS course without showing some proficiency in BLS. The morning overall though went fairly well, as we practiced doing CPR and using an Automated External Defibrillator (AED). You have to show proficiency at both to pass the course, meaning they watch you do the entire sequence one time of CPR followed by AED use without any guidance, and then pass you.

Following lunch, we spent the afternoon going over the pulseless resuscitation pathway. The sequence has many details but the takehome point is that if they have fibrillation, then you defibrillate; otherwise, you do not. Pretty simple, right? Heh.

After Day 1, I went home and tried to cram the rest of the cases into my head, but was too tired and fell asleep.

Advanced Cardiac Life Support Training Day 2

I woke up extra early to try to finish off the cases and do the pre-tests. Unfortunately for me, I didn't finish the cases and did poorly on the pre-tests. Fortunately for you, I'm here to tell you that if you are awake and pay attention during the course instruction, you will pass the course easily. Still, it really really helps to have read the cases beforehand and memorized the drugs / doses.

Day 2 primarily consisted of going over what to do when the person does have a pulse but has a worrisome rhythm. My group was lucky to have a great instructor who basically went over all the scenarios twice for all of us during this session. He even told us that the test would be exactly the same, except that instead of making comments he would grade us. We then broke for lunch, after which we returned and took the exam. As our instructor said, it went exactly as before, except that he made no comments this time. After a short break, we took a written exam.

The written exam was 25 questions long, concerning mostly material from the ACLS provider manual. However, one could easily pass if they had just paid attention during the training. You could miss up to 4 questions and still get a passing grade. The pass rate according to the trainers was nearly 99%, and needless to say, everyone in my group passed.

Overall, it was a good experience and useful training. It surprises me though, that we are allowed to go into clinics in the US and through medical school without receiving this training beforehand. If you are still a medical student and are interested in cardiology, cardiothoracic surgery, anesthesia, or critical care, I would highly recommend that you take this course so that you look like a rockstar to your attending and teams. I feel that by being ACLS certified, I am now a more competent doctor. Now, I just have to figure out a way to remain sharp at it without ever having to use it =)

Sunday, June 07, 2009

I graduated from medical school this past week. Thank you to everyone who supported me along the way and congratulated me at the conclusion. And, thanks to you readers for being there along the journey, hopefully learning a bit when I fell and laughing with me when I rose again.

As for my absence from this blog, it's easily explained: fourth year! I was fortunate enough to get some time off after match day and travel. I spent several weeks in India, visiting family all over Rajasthan and Maharashtra, including my 88 year old grandmother. After seeing my relatives, I met up with a few friends from med school in Delhi to fly to Nepal and go trekking in the Himalayas. We spent a few days in Kathmandu (the capital of Nepal) and then took a 6 hour bus ride to Pokhara, the second largest city in Nepal, which is located in the Annapurna region of the Himalayas in western Nepal. From Pokhara, we began a 10 day trek through the Annapurna region, ending at the Annapurna Base Camp. Words cannot describe the vistas we saw, and I believe everyone in the group has memories that will last a lifetime.

Macchapuchare (Fishtail Mountain) From Tadapani

After returning, I spent a week in California, finding an apartment, and then returned home. Graduation itself was great. Everyone was excited, catching up on all their senior spring adventures and talking about the future. I think our graduation ceremony was fairly standard. There were speeches by our President and Deans, followed by our keynote speaker. Subsequently, the degrees were conferred by the President, after which we had the procession during which we were hooded by selected faculty members, and then walked across the stage to receive our diploma from our President. I forget the order a bit here, but I think after we all had our diplomas, we rose to take the Hippocratic Oath.

According to Wikipedia, "The Hippocratic Oath is an oath traditionally taken by physicians pertaining to the ethical practice of medicine. It is widely believed that the oath was written by Hippocrates, the father of western medicine, in the 4th century BC, or by one of his students." There are several modern translations of the oath, but the one we used was as follows:

I do solemnly swear, by whatever I hold most sacred: That I will be loyal to the profession of medicine and just and generous to its members;

That I will lead my life and practice my profession in uprightness and honor;

That into whatsoever house I shall enter, it shall be for the good of the sick to the utmost of my power, holding myself far aloof from wrong, from corruption, from the tempting of others to vice;

That I will exercise my profession solely for the cure of my patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited; far less suggest it.

That whatsoever I shall see or hear of the lives of men which is not fitting to be spoken, I will keep inviolably secret. These things I do swear.

And now, should I be true to this, my oath, may prosperity and good repute ever be mine; the opposite, should I prove myself forsworn.

After the ceremony, everyone gathered in the lobby, reuniting with family and friends to celebrate the occasion. Since then, I have been busy packing and preparing to move. Along with those preparations, I am considering the future direction of this blog. I have enjoyed working on it and developing to this point, and think I shall I continue to contribute to it. However, I am weighing several options about to how to proceed. Any comments with ideas or suggestions would be more than welcome. I hope this blog has been beneficial to you, the reader, and I thank you again for your support along the way.

Monday, April 13, 2009

Back in January, I devoted this blog to posting all the advice I had for USMLE Step 1. For my medical school, that was the time during which many people were taking Step 1. However, I realize that many people end up taking the exam in May and June. In case you missed a post, here is the entire list of posts containing my USMLE Step 1 Advice:

Wednesday, April 08, 2009

I'll be enjoying a much deserved MS4 vacation over the next few weeks, but hopefully I'll be able to get in a few posts. As things have been slowing down, I decided to peruse my blog stats for the year thus far. The traffic to this site has shifted a bit, with more people coming here searching for informaiton on USMLE Step 1, but Dale Dubin remains popular as ever. Anyway, here are my top 9 in '09 (so far):

Monday, March 30, 2009

Three days ago, I took USMLE Step 2 CS. The CS stands for Clinical Skills. Unlike the other exams, this one is not computer-based and instead involves live, standardized patients. Relative to USMLE Step 1 or even USMLE Step 2 CK, preparing for Step 2 CS is a much shorter, much more straightforward process. Since Step 2 CS is graded on a pass / fail basis, the goal here is also much simpler: pass!

USMLE Step 2 CS Exam Format

The basic format of Step 2 CS is a patient encounter. A patient encounter consists of a focused history and physical exam conducted in 15 minutes, followed by a patient note, for which you are given 10 minutes. The note includes pertinent positives and negatives from the history and the physical, as well as a differential and plan. The differential and plan can have up to 5 items on them, each. There are 12 patient encounters throughout the day. The first five are followed by a thirty minute break for lunch, the next 4 are followed by a 15 minute break, and then the day ends with the last 3 encounters. The exam is only given at 5 locations throughout the United States: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. On top of that, it costs over a $1000! The USMLE site has a more extensive description of the clinical skills exam here.

USMLE Step 2 CS Study Schedule

I'd say I spent about a week studying for the exam. I read through First Aid for the USMLE Step 2 CS, first familiarizing myself with the format of the test and basic differentials for common complaints. Then, I recruited one of my medical school friends to play the standardized patient for me and went through some of the cases at the end of the book. Even though I was unable to complete all the cases, I felt pretty comfortable going into the exam.

As far as preparing goes, my advice would be to take Step 2 CK before CS. If you have a good fund of knowledge for CK, you will be more than prepared for CS. Also, when writing the patient note, use the computer as it will be faster and easier to edit than pen & paper. Oh, and bring your own lunch and snacks. They provide food, but your own food will probably be better. Other than that, just remain calm and you'll do just fine.Updated 2015-12-18

Sunday, March 15, 2009

What is Match Day?For those of you who are not aware, Match Day is the day that U.S. medical students (and foreign medical graduates applying for residency positions in the United States) learn where they will be going for internship and residency the following year. The National Resident Matching Program (NRMP) is the entity that coordinates the Match Day process. It begins in the summer of the previous year, when students begin filling out the Electronic Residency Application Service (ERAS) application. They are allowed to submit it after September 1 to programs of their interest. Programs invite applicants for interviews between November and January. After interview season, applicants rank programs on a Rank Order List (ROL) which they submit to NRMP by the end of February. At the same time, programs rank all the applicants they interviewed. Between the end of February and the middle of March, NRMP runs a computer program with the Match algorithm to determine where each applicant matched, and the results are revealed in the middle of March.

The Week of the MatchThe Match week follows the same pattern each year. The schedule for the 2009 Match is as follows: on Monday, March 16, applicants are notified by email or on the Web whether or not they matched to some program. They are not notified which program. If they did not match for an preliminary / intern year, advanced position, or categorical position, they will enter the Scramble in an attempt to secure a spot that went unfilled in the regular Match (a topic for another post). By noon on Tuesday, March 17, the list of unfilled programs is released. Match Day ceremonies at medical schools across the nation on Thursday, March 19. At my institution, the basic schedule is: class photo at 10am, speeches til 11am, at which point a board with all our results in envelopes is brought out. At 11, we all rush to the board and rip open our envelopes to find out the results. In the afternoon, there is a party at our Dean's house, followed by a class party that night. Now, for comparison, some other schools have an even more formal ceremony, where each student goes on stage, walks across to a Dean, who hands them an envelope. The student is then required to open the envelope and read the results to the entire audience of classmates, teachers, family, and friends. I am not a fan of that approach. Not only is the process longer, I feel it also violates the student's privacy and right to divulge that information in the manner he or she sees fit. Regardless, most people will be happy enough with the result after four long years of hard work.

Match Day Gift ListNow, for all those family and friends gathered, this is a time of celebration for the soon-to-be M.D. What gift is most appropriate? Frankly, I do not know since the event is still a week away for me, but if anyone out there wants to buy me something, here are some ideas! Heh, I will try to suggest things that I think are generally applicable and hopefully useful for a future intern.Interns work long hours. It's just a fact. And given that fact, interns drink coffee. Lots of it. What better gift than a single cup than a Black & Decker Personal Coffeemaker with Travel Mug? They are not going to get through morning report without it.

After working all those long hours, interns and residents need something to kick back and relax. How about a Nintendo Wii Console? Or, if they already have one, maybe get them something to play on it, like Rock Band 2. The Wii is especially nice since it requires one to be marginally more active than with other consoles, which interns can use to fool themselves into thinking they exercised for the day.

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Of course, internship is not all fun and games. There is a lot of reading to be done. But, not all of it has to be of the "Harrison's" / Pocket Medicine kind. For the latest in reading technology, check out Amazon's Kindle. As thin as a magazine, and about as light, the Kindle lets you wirelessly download e-books and read them anywhere. While the cost of the Kindle is a bit pricey, the average cost per book is cheaper (about $10). Also, the books download to your Kindle almost instantaneously, so no waiting at a bookstore or waiting for something to ship.

A particularly useful title (that is actually available on the Kindle) is Personal Finance For Dummies. Now, I picked the title because I have enjoyed the 'Dummies' series in the past, but I cannot say I have used this book in particular. My point in including this title is that, for many interns/residents, this is their first real job. Yet, for all their knowledge of medicine, many know very little about personal finance. It is especially important to educate one's self about these issues, as one not only begins to earn a salary but also has to begin repaying student loans. So, while not the 'sexiest' gift, a book on personal finance could turn out to be the most useful.

And, since another 4 years have passed, it may be time for a new laptop. Just a thought =) You reading this, Dad??

While clearly not a comprehensive list, hopefully this gives you a few ideas on some practical gifts for the newly Matched loved one in your life.